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Please answer the following questions as completely as possible,and to the best of your knowledge. 1. Your existing septic system consists of(check all that apply): b Septic Tank El Disposal Trenches ❑ Capping Fill 0 Sandfilter 0 Seepage Bed 0 Cesspool or Pit 0 Unknown 0 Other (Describe) 2. When wasyour septic system installed? 401 fl°cur i t PermitNumber (Da e) ( ) 3. Tank material: J2I Concrete 0 Steel 0 Plastic or Fiberglass 0 Unknown 4. Septic tank volume(in gallons) /000 2. f 5. When-was theseptic tank,last pumped? .'O / Attach receipt if available. 6. Number of disposal trenches / r 7. Total length of disposal trenches(in feet) /..:716 in /24.us.e 720 -' fJ 7,4.� ' / D '�`h 8. Do you propose to use the existing septic system? Yes 1'4 No❑ 9. Is your septic system currently in use? Yes fa No❑ If no,date of last use. 10. If the septic system currently serves a dwelling: How many bedrooms are in the dwelling? / How many people occupy the dwelling? / 11. How many bedrooms will be in the proposed dwelling? How ir many occupants? 12. If the septic systemserves a business: How many total employees are there? Type of business 13. Is there a proposed change of use of your structure(home or business•},? Yes 0 No❑ If yes, please explain -5110/1 i)€irlq r rriede4 r /17;r 7 sh 179 tine.. i.06,iifi, 14. Provide a plot plan (sketch)on the reverse side of'this form showing the best estimated or actual measurements that locate the existing septic tank and disposaltrenches,property lines,easements, existing structures,driveways,and water supply. Indicate the direction of north. If you are proposing to replace the septic system, indicate the test hole location. By my signature, I certify that the above information and the plot plan on the reverse side of this form are accurate and true to the best of my knowledge. t 9 '(Date) ,/Signature of Property Owner or Legally Authorized Representative — — Office use only:Record of existing.system: Yes❑ No 0 Attached 0 Date Issued Permit Number Certificate of Satisfactory Completion Issued: YesC1 Rote Initials Other file information: I